The Hospitalist

HM16 Presenters: Dr. Scott Rissmiller, Dr. Steve Deitelzweig, Dr. Jerome Siy, Dr. Thomas Mcllraith, and Dr. Michael Reitz

Summary: This session at #HospMed16 explored lessons learned from five hospitalist leaders across the country about improving hospitalist practice through enhancing hospitalist engagement, group communication, and leadership development. It was proposed that the “new” value equation is [Engagement * (quality/cost)] = Value. Engagement is the multiplier of value. The speakers highlighted the following:

Build a Plan : Approach engagement like any other business plan with metrics, accountability, and “S.M.A.R.T." goals.

Build Trust: Visibility breeds credibility. Credibility breeds Trust. Trust encourages Engagement.

Build Transparency: Keep communication simple and be sure that it’s helpful information.

Build Leaders: All hospitalists are leaders. Strong leadership skills promote effective communication across the system. Nurture leadership skills for the right level of leadership, to find the right seat on the bus.

Build Celebrations: Celebrate successes, and learn from failure. TH

HM16 Presenters: Dr. Scott Rissmiller, Dr. Steve Deitelzweig, Dr. Jerome Siy, Dr. Thomas Mcllraith, and Dr. Michael Reitz

Summary: This session at #HospMed16 explored lessons learned from five hospitalist leaders across the country about improving hospitalist practice through enhancing hospitalist engagement, group communication, and leadership development. It was proposed that the “new” value equation is [Engagement * (quality/cost)] = Value. Engagement is the multiplier of value. The speakers highlighted the following:

Build a Plan : Approach engagement like any other business plan with metrics, accountability, and “S.M.A.R.T." goals.

Build Trust: Visibility breeds credibility. Credibility breeds Trust. Trust encourages Engagement.

Build Transparency: Keep communication simple and be sure that it’s helpful information.

Build Leaders: All hospitalists are leaders. Strong leadership skills promote effective communication across the system. Nurture leadership skills for the right level of leadership, to find the right seat on the bus.

Build Celebrations: Celebrate successes, and learn from failure. TH

HM16 Presenters: Dr. Scott Rissmiller, Dr. Steve Deitelzweig, Dr. Jerome Siy, Dr. Thomas Mcllraith, and Dr. Michael Reitz

Summary: This session at #HospMed16 explored lessons learned from five hospitalist leaders across the country about improving hospitalist practice through enhancing hospitalist engagement, group communication, and leadership development. It was proposed that the “new” value equation is [Engagement * (quality/cost)] = Value. Engagement is the multiplier of value. The speakers highlighted the following:

Build a Plan : Approach engagement like any other business plan with metrics, accountability, and “S.M.A.R.T." goals.

Build Trust: Visibility breeds credibility. Credibility breeds Trust. Trust encourages Engagement.

Build Transparency: Keep communication simple and be sure that it’s helpful information.

Build Leaders: All hospitalists are leaders. Strong leadership skills promote effective communication across the system. Nurture leadership skills for the right level of leadership, to find the right seat on the bus.

Build Celebrations: Celebrate successes, and learn from failure. TH

Caring for patients in the inpatient setting is complex and often requires consultation from specialists. Yet the actual skill of obtaining a consult is rarely taught. Medical students and residents usually learn by trial and error, becoming targets of frustrated consultants and suffering humiliation and much anxiety. To facilitate communication between the primary team and the specialist, we propose that the student and/or resident start by asking the following questions.

1. Why Call This Consult?

To decide whether you need a consult, first determine the type. Consultations can be broken down into three different types: advice on diagnosis, advice on management, or arrangements for a specific procedure or test. Advice on diagnosis or management is typically required when a clinical issue has reached the bounds of knowledge, experience, or comfort zone of the team or physician (e.g., idiopathic leukocytosis). For procedures, a consultant who is licensed to perform the procedure may be required (e.g., endoscopy for GI bleed).

2. What Should Be Done before a Consult Is Requested?

First, ask yourself, “If I were the consultant, what would I want to know?” Before calling, put yourself in the shoes of the consultant and consider the available data carefully to develop your own hypotheses. For example, infectious disease consultants typically make judgments based on relevant culture data, current and/or past antibiotics, imaging, and signs or symptoms of active infection. Reading about the problem beforehand allows you to anticipate possible questions and consider additional studies that may be requested by the consultant. It also helps ascertain whether the consultation is actually necessary or targeted to the right team.

3. What Is the Clinical Question?

Bergus and colleagues found that a well-structured clinical question clearly identifies the treatment the primary doctor is proposing and the desired outcomes for the patient.1 For instance, rather than asking, “What should we do for this 75-year-old man with chest pain?”, a better question might be, “Will the addition of ranolazine increase exercise tolerance in our 75-year-old man with angina who is already taking a beta blocker and nitrates?” When both components are present, clinical questions are more likely to be answered.

4. How Do I Best Present the Case to My Consultant?

Requesting a consultation requires a succinct presentation that focuses on the aspects of the case most pertinent to the specialist. To do this, again put yourself in the shoes of the consultant. For example, a patient’s history of venous thromboembolism (VTE) will always be relevant to a hematologist, whereas a history of GERD may not be needed in your initial conversation. Limit the initial presentation to two to three minutes and organize using the four I’s:

1. Introduction: “My name is X with blue medicine team; I am calling to request a consult.”
2. Information: Patient name, location, medical record number, attending physician.
3. Inquiry: “I am requesting evaluation for an EGD in a patient with an upper GI bleed.”
4. Important items (the story): “Mr. X is a 55-year-old male with history of peptic ulcer disease presenting with abdominal pain.”

5. What Data Requests Should I Anticipate?

Have your clinical data easily accessible in case additional information is requested (i.e., keep the chart open when calling). If certain tests are predictably going to be needed by the specialist (e.g., renal ultrasound for a nephrologist), make sure that the results are available or in process. Also, be prepared to take notes if the consultant requests additional tests up front.

6. How Urgent Is the Consult?

Consultations can be emergent, urgent, or elective. Directly communicate any emergent or urgent consults in order to clarify the issues expeditiously. For more routine consults, consider delaying the call until enough laboratory data or imaging is available for the consultant to answer the question. Do not call a nonurgent consult at the end of the day or on a weekend.

7. Where Can I Meet with the Consultant to Discuss the Case?

Be available to your consultants by offering the fastest and most reliable means for them to get in touch with you. Take advantage of your consultants and learn from them. Be where they are: If looking at the blood smear, join them. If spinning the urine, ask to examine the sediment together. Discussing the case in person demonstrates your interest, engendering a more serious and perhaps expeditious consideration of your case. Finally, request seminal articles that have driven their decision to allow for more intelligent conversations in the future.

8. How Can I Nurture My Relationship with the Consulting Team?

The best relationships with consultants require give-and-take. Be a reliable source by providing accurate documentation of ongoing events, history and physical examination, and laboratory data in your notes. Understand consultant recommendations and summarize these in your plan. Avoid “Plan per Renal/GI/Cards/Heme, etc.” in your notes. Continue to think about the questions and issues and read on your own. If you are unclear about the recommendations, clarify them with the consulting team. Speaking with consultants is a learning opportunity; never forget to ask why they have made a certain recommendation. Avoid “chart wars” if there are points of disagreement with the plan or recommendations.

9. How Do I Close the Loop on the Consult?

Closing the communication loop is one of the most important aspects of the consult because it allows you to act on the recommendations. Remember that consultants are likely to be as busy as you are (if not busier). If the consult was urgent, call consultants directly for guidance. If it wasn’t urgent, look in the chart first for their note. Checking the chart later in the day could help to avoid unnecessary phone calls and increase your efficiency.

10. Am I Sure I Want a Curbside Consult?

In a curbside consult, you request advice of an expert who is neither in the presence of the patients nor has a therapeutic relationship with them. A study by Burden and colleagues in 2013 found that 55% of physicians offered different advice in formal consultation than in a curbside consultation, and 60% felt that formal consultation changed management.2 Similarly, Kuo and colleagues noted that 77% of subspecialists reported that important clinical findings were frequently missing from curbsides.3 Some recommend limiting curbsides to simple questions that don’t require consultants to assess multiple variables; as a courtesy, consider offering them the option of a formal consult. Ultimately, the decision to request a curbside consultation, and any consultation for that matter, should always be discussed with your attending physician.

Conclusion

Effective communication with consultants requires forethought and is an exercise in clinical reasoning of great educational value to students and residents. By considering the questions above, the consultative experience can be more productive for both the primary and consulting team and will enhance the care of the hospitalized patient. TH

Dr. Esquivel is a hospitalist in the Division of Hospital Medicine at Weill Cornell Medical College in New York City. Dr. Rendon is a hospitalist in the Division of Hospital Medicine at the University of New Mexico in Albuquerque.

References

1. Bergus GR, Randall CS, Sinift SD, Rosenthal DM. Does the structure of clinical questions affect the outcome of curbside consultations with specialty colleagues? Arch Fam Med. 2000;9(6):541-547.

2. Burden M, Sarcone E, Keniston A, et al. Prospective comparison of curbside versus formal consultations. J Hosp Med. 2013;8(1):31-35.

3. Kuo D, Gifford DR, Stein MD. Curbside consultation practices and attitudes among primary care physicians and medical subspecialists. JAMA. 1998;280(10):905-909.

Caring for patients in the inpatient setting is complex and often requires consultation from specialists. Yet the actual skill of obtaining a consult is rarely taught. Medical students and residents usually learn by trial and error, becoming targets of frustrated consultants and suffering humiliation and much anxiety. To facilitate communication between the primary team and the specialist, we propose that the student and/or resident start by asking the following questions.

1. Why Call This Consult?

To decide whether you need a consult, first determine the type. Consultations can be broken down into three different types: advice on diagnosis, advice on management, or arrangements for a specific procedure or test. Advice on diagnosis or management is typically required when a clinical issue has reached the bounds of knowledge, experience, or comfort zone of the team or physician (e.g., idiopathic leukocytosis). For procedures, a consultant who is licensed to perform the procedure may be required (e.g., endoscopy for GI bleed).

2. What Should Be Done before a Consult Is Requested?

First, ask yourself, “If I were the consultant, what would I want to know?” Before calling, put yourself in the shoes of the consultant and consider the available data carefully to develop your own hypotheses. For example, infectious disease consultants typically make judgments based on relevant culture data, current and/or past antibiotics, imaging, and signs or symptoms of active infection. Reading about the problem beforehand allows you to anticipate possible questions and consider additional studies that may be requested by the consultant. It also helps ascertain whether the consultation is actually necessary or targeted to the right team.

3. What Is the Clinical Question?

Bergus and colleagues found that a well-structured clinical question clearly identifies the treatment the primary doctor is proposing and the desired outcomes for the patient.1 For instance, rather than asking, “What should we do for this 75-year-old man with chest pain?”, a better question might be, “Will the addition of ranolazine increase exercise tolerance in our 75-year-old man with angina who is already taking a beta blocker and nitrates?” When both components are present, clinical questions are more likely to be answered.

4. How Do I Best Present the Case to My Consultant?

Requesting a consultation requires a succinct presentation that focuses on the aspects of the case most pertinent to the specialist. To do this, again put yourself in the shoes of the consultant. For example, a patient’s history of venous thromboembolism (VTE) will always be relevant to a hematologist, whereas a history of GERD may not be needed in your initial conversation. Limit the initial presentation to two to three minutes and organize using the four I’s:

1. Introduction: “My name is X with blue medicine team; I am calling to request a consult.”
2. Information: Patient name, location, medical record number, attending physician.
3. Inquiry: “I am requesting evaluation for an EGD in a patient with an upper GI bleed.”
4. Important items (the story): “Mr. X is a 55-year-old male with history of peptic ulcer disease presenting with abdominal pain.”

5. What Data Requests Should I Anticipate?

Have your clinical data easily accessible in case additional information is requested (i.e., keep the chart open when calling). If certain tests are predictably going to be needed by the specialist (e.g., renal ultrasound for a nephrologist), make sure that the results are available or in process. Also, be prepared to take notes if the consultant requests additional tests up front.

6. How Urgent Is the Consult?

Consultations can be emergent, urgent, or elective. Directly communicate any emergent or urgent consults in order to clarify the issues expeditiously. For more routine consults, consider delaying the call until enough laboratory data or imaging is available for the consultant to answer the question. Do not call a nonurgent consult at the end of the day or on a weekend.

7. Where Can I Meet with the Consultant to Discuss the Case?

Be available to your consultants by offering the fastest and most reliable means for them to get in touch with you. Take advantage of your consultants and learn from them. Be where they are: If looking at the blood smear, join them. If spinning the urine, ask to examine the sediment together. Discussing the case in person demonstrates your interest, engendering a more serious and perhaps expeditious consideration of your case. Finally, request seminal articles that have driven their decision to allow for more intelligent conversations in the future.

8. How Can I Nurture My Relationship with the Consulting Team?

The best relationships with consultants require give-and-take. Be a reliable source by providing accurate documentation of ongoing events, history and physical examination, and laboratory data in your notes. Understand consultant recommendations and summarize these in your plan. Avoid “Plan per Renal/GI/Cards/Heme, etc.” in your notes. Continue to think about the questions and issues and read on your own. If you are unclear about the recommendations, clarify them with the consulting team. Speaking with consultants is a learning opportunity; never forget to ask why they have made a certain recommendation. Avoid “chart wars” if there are points of disagreement with the plan or recommendations.

9. How Do I Close the Loop on the Consult?

Closing the communication loop is one of the most important aspects of the consult because it allows you to act on the recommendations. Remember that consultants are likely to be as busy as you are (if not busier). If the consult was urgent, call consultants directly for guidance. If it wasn’t urgent, look in the chart first for their note. Checking the chart later in the day could help to avoid unnecessary phone calls and increase your efficiency.

10. Am I Sure I Want a Curbside Consult?

In a curbside consult, you request advice of an expert who is neither in the presence of the patients nor has a therapeutic relationship with them. A study by Burden and colleagues in 2013 found that 55% of physicians offered different advice in formal consultation than in a curbside consultation, and 60% felt that formal consultation changed management.2 Similarly, Kuo and colleagues noted that 77% of subspecialists reported that important clinical findings were frequently missing from curbsides.3 Some recommend limiting curbsides to simple questions that don’t require consultants to assess multiple variables; as a courtesy, consider offering them the option of a formal consult. Ultimately, the decision to request a curbside consultation, and any consultation for that matter, should always be discussed with your attending physician.

Conclusion

Effective communication with consultants requires forethought and is an exercise in clinical reasoning of great educational value to students and residents. By considering the questions above, the consultative experience can be more productive for both the primary and consulting team and will enhance the care of the hospitalized patient. TH

Dr. Esquivel is a hospitalist in the Division of Hospital Medicine at Weill Cornell Medical College in New York City. Dr. Rendon is a hospitalist in the Division of Hospital Medicine at the University of New Mexico in Albuquerque.

References

1. Bergus GR, Randall CS, Sinift SD, Rosenthal DM. Does the structure of clinical questions affect the outcome of curbside consultations with specialty colleagues? Arch Fam Med. 2000;9(6):541-547.

2. Burden M, Sarcone E, Keniston A, et al. Prospective comparison of curbside versus formal consultations. J Hosp Med. 2013;8(1):31-35.

3. Kuo D, Gifford DR, Stein MD. Curbside consultation practices and attitudes among primary care physicians and medical subspecialists. JAMA. 1998;280(10):905-909.

Caring for patients in the inpatient setting is complex and often requires consultation from specialists. Yet the actual skill of obtaining a consult is rarely taught. Medical students and residents usually learn by trial and error, becoming targets of frustrated consultants and suffering humiliation and much anxiety. To facilitate communication between the primary team and the specialist, we propose that the student and/or resident start by asking the following questions.

1. Why Call This Consult?

To decide whether you need a consult, first determine the type. Consultations can be broken down into three different types: advice on diagnosis, advice on management, or arrangements for a specific procedure or test. Advice on diagnosis or management is typically required when a clinical issue has reached the bounds of knowledge, experience, or comfort zone of the team or physician (e.g., idiopathic leukocytosis). For procedures, a consultant who is licensed to perform the procedure may be required (e.g., endoscopy for GI bleed).

2. What Should Be Done before a Consult Is Requested?

First, ask yourself, “If I were the consultant, what would I want to know?” Before calling, put yourself in the shoes of the consultant and consider the available data carefully to develop your own hypotheses. For example, infectious disease consultants typically make judgments based on relevant culture data, current and/or past antibiotics, imaging, and signs or symptoms of active infection. Reading about the problem beforehand allows you to anticipate possible questions and consider additional studies that may be requested by the consultant. It also helps ascertain whether the consultation is actually necessary or targeted to the right team.

3. What Is the Clinical Question?

Bergus and colleagues found that a well-structured clinical question clearly identifies the treatment the primary doctor is proposing and the desired outcomes for the patient.1 For instance, rather than asking, “What should we do for this 75-year-old man with chest pain?”, a better question might be, “Will the addition of ranolazine increase exercise tolerance in our 75-year-old man with angina who is already taking a beta blocker and nitrates?” When both components are present, clinical questions are more likely to be answered.

4. How Do I Best Present the Case to My Consultant?

Requesting a consultation requires a succinct presentation that focuses on the aspects of the case most pertinent to the specialist. To do this, again put yourself in the shoes of the consultant. For example, a patient’s history of venous thromboembolism (VTE) will always be relevant to a hematologist, whereas a history of GERD may not be needed in your initial conversation. Limit the initial presentation to two to three minutes and organize using the four I’s:

1. Introduction: “My name is X with blue medicine team; I am calling to request a consult.”
2. Information: Patient name, location, medical record number, attending physician.
3. Inquiry: “I am requesting evaluation for an EGD in a patient with an upper GI bleed.”
4. Important items (the story): “Mr. X is a 55-year-old male with history of peptic ulcer disease presenting with abdominal pain.”

5. What Data Requests Should I Anticipate?

Have your clinical data easily accessible in case additional information is requested (i.e., keep the chart open when calling). If certain tests are predictably going to be needed by the specialist (e.g., renal ultrasound for a nephrologist), make sure that the results are available or in process. Also, be prepared to take notes if the consultant requests additional tests up front.

6. How Urgent Is the Consult?

Consultations can be emergent, urgent, or elective. Directly communicate any emergent or urgent consults in order to clarify the issues expeditiously. For more routine consults, consider delaying the call until enough laboratory data or imaging is available for the consultant to answer the question. Do not call a nonurgent consult at the end of the day or on a weekend.

7. Where Can I Meet with the Consultant to Discuss the Case?

Be available to your consultants by offering the fastest and most reliable means for them to get in touch with you. Take advantage of your consultants and learn from them. Be where they are: If looking at the blood smear, join them. If spinning the urine, ask to examine the sediment together. Discussing the case in person demonstrates your interest, engendering a more serious and perhaps expeditious consideration of your case. Finally, request seminal articles that have driven their decision to allow for more intelligent conversations in the future.

8. How Can I Nurture My Relationship with the Consulting Team?

The best relationships with consultants require give-and-take. Be a reliable source by providing accurate documentation of ongoing events, history and physical examination, and laboratory data in your notes. Understand consultant recommendations and summarize these in your plan. Avoid “Plan per Renal/GI/Cards/Heme, etc.” in your notes. Continue to think about the questions and issues and read on your own. If you are unclear about the recommendations, clarify them with the consulting team. Speaking with consultants is a learning opportunity; never forget to ask why they have made a certain recommendation. Avoid “chart wars” if there are points of disagreement with the plan or recommendations.

9. How Do I Close the Loop on the Consult?

Closing the communication loop is one of the most important aspects of the consult because it allows you to act on the recommendations. Remember that consultants are likely to be as busy as you are (if not busier). If the consult was urgent, call consultants directly for guidance. If it wasn’t urgent, look in the chart first for their note. Checking the chart later in the day could help to avoid unnecessary phone calls and increase your efficiency.

10. Am I Sure I Want a Curbside Consult?

In a curbside consult, you request advice of an expert who is neither in the presence of the patients nor has a therapeutic relationship with them. A study by Burden and colleagues in 2013 found that 55% of physicians offered different advice in formal consultation than in a curbside consultation, and 60% felt that formal consultation changed management.2 Similarly, Kuo and colleagues noted that 77% of subspecialists reported that important clinical findings were frequently missing from curbsides.3 Some recommend limiting curbsides to simple questions that don’t require consultants to assess multiple variables; as a courtesy, consider offering them the option of a formal consult. Ultimately, the decision to request a curbside consultation, and any consultation for that matter, should always be discussed with your attending physician.

Conclusion

Effective communication with consultants requires forethought and is an exercise in clinical reasoning of great educational value to students and residents. By considering the questions above, the consultative experience can be more productive for both the primary and consulting team and will enhance the care of the hospitalized patient. TH

Dr. Esquivel is a hospitalist in the Division of Hospital Medicine at Weill Cornell Medical College in New York City. Dr. Rendon is a hospitalist in the Division of Hospital Medicine at the University of New Mexico in Albuquerque.

References

1. Bergus GR, Randall CS, Sinift SD, Rosenthal DM. Does the structure of clinical questions affect the outcome of curbside consultations with specialty colleagues? Arch Fam Med. 2000;9(6):541-547.

2. Burden M, Sarcone E, Keniston A, et al. Prospective comparison of curbside versus formal consultations. J Hosp Med. 2013;8(1):31-35.

3. Kuo D, Gifford DR, Stein MD. Curbside consultation practices and attitudes among primary care physicians and medical subspecialists. JAMA. 1998;280(10):905-909.

NEW YORK (Reuters Health) - Clinical practice in management of early-onset sepsis (EOS) in newborns varies widely across Europe, North America and Asia, new survey results show.

National guidelines also disagree on when to start antibiotics in low-risk situations, and how to decide to stop therapy in high-risk scenarios, Dr. Wendy van Herk of Erasmus MC University Medical Center-Sophia Children's Hospital in Rotterdam, the Netherlands, and colleagues found."

A discussion leading to terms of a threshold to treat neonates with low infection risk, prospective studies ofstrategies regarding early discontinuation of unnecessary antibiotic therapy with safety endpoints acknowledging different backgrounds of health care systems, and clear and concise guidelines followed by research to study the impact are mandatory to improve management of term and late preterm infants at risk for EOS," they write in their report, online January 13 in The Pediatric Infectious Disease Journal.

Up to 15% of term and late-preterm neonates are evaluated for suspected EOS, and 10% receive intravenous antibiotics within the first three days of life, the researchers note. But the incidence of culture-proven EOS in term and late-preterm newborns is less than 0.1%, they add.

To investigate current management of suspected EOS, the researchers surveyed pediatricians and neonatologists and reviewed guidelines from Canada, the United States, the United Kingdom, Switzerland and Belgium. A total of 439 clinicians responded to the survey.

In response to a question about whether they would start antibiotic treatment in a scenario rated "low risk" for EOS, 29% of physicians said they would, 26% would not, and 45% said they would start treatment if the patients' laboratory markers were abnormal. Nearly all of the respondents (99%) said they would initiate antibiotics in a high-risk scenario.

In the low-risk situation, 89% said they would stop antibiotic treatment before 72 hours. In the high-risk scenario, 35% said they would stop antibiotics before 72 hours, 56% said they would continue treatment for five to seven days, and 9% said they would treat patients for more than seven days.

Overall, 31% of the survey respondents said they would base their decision to start antibiotic treatment on laboratory investigations, while 72% said they would do so when deciding to continue treatment. Most said they would use complete blood count (CBC) and C-reactive protein (CRP), while a small minority said they would use newer inflammation markers including procalcitonin (PCT) and interleukins.

While all the guidelines reviewed recommended treating newborns with clinical signs indicating infection, and re-evaluating whether patients needed more antibiotics at 36 to 48 hours, they did not provide specific advice on treatment when newborns had prolonged clinical signs of infection or high levels of infection markers. All guidelines recommended using CBC or CRP, while only one included PCT.

Dr. van Herk and colleagues also compared the guidelines for each country with the survey responses of physicians from that country, and found most followed national guidelines on when to start or discontinue antibiotics.

"The diversity with regards to duration of antibiotic therapy in higher risk situations raises the question, what are safe strategies to minimize duration of antibiotic therapy without under-treatment of truly septic neonates?" the authors write. "Currently, the duration of antibiotic therapy is controversial even for proven infection. Prospective, international, multicenter trials studying newer infection markers with a safety endpoint may be helpful in answering this question."

NEW YORK (Reuters Health) - Clinical practice in management of early-onset sepsis (EOS) in newborns varies widely across Europe, North America and Asia, new survey results show.

National guidelines also disagree on when to start antibiotics in low-risk situations, and how to decide to stop therapy in high-risk scenarios, Dr. Wendy van Herk of Erasmus MC University Medical Center-Sophia Children's Hospital in Rotterdam, the Netherlands, and colleagues found."

A discussion leading to terms of a threshold to treat neonates with low infection risk, prospective studies ofstrategies regarding early discontinuation of unnecessary antibiotic therapy with safety endpoints acknowledging different backgrounds of health care systems, and clear and concise guidelines followed by research to study the impact are mandatory to improve management of term and late preterm infants at risk for EOS," they write in their report, online January 13 in The Pediatric Infectious Disease Journal.

Up to 15% of term and late-preterm neonates are evaluated for suspected EOS, and 10% receive intravenous antibiotics within the first three days of life, the researchers note. But the incidence of culture-proven EOS in term and late-preterm newborns is less than 0.1%, they add.

To investigate current management of suspected EOS, the researchers surveyed pediatricians and neonatologists and reviewed guidelines from Canada, the United States, the United Kingdom, Switzerland and Belgium. A total of 439 clinicians responded to the survey.

In response to a question about whether they would start antibiotic treatment in a scenario rated "low risk" for EOS, 29% of physicians said they would, 26% would not, and 45% said they would start treatment if the patients' laboratory markers were abnormal. Nearly all of the respondents (99%) said they would initiate antibiotics in a high-risk scenario.

In the low-risk situation, 89% said they would stop antibiotic treatment before 72 hours. In the high-risk scenario, 35% said they would stop antibiotics before 72 hours, 56% said they would continue treatment for five to seven days, and 9% said they would treat patients for more than seven days.

Overall, 31% of the survey respondents said they would base their decision to start antibiotic treatment on laboratory investigations, while 72% said they would do so when deciding to continue treatment. Most said they would use complete blood count (CBC) and C-reactive protein (CRP), while a small minority said they would use newer inflammation markers including procalcitonin (PCT) and interleukins.

While all the guidelines reviewed recommended treating newborns with clinical signs indicating infection, and re-evaluating whether patients needed more antibiotics at 36 to 48 hours, they did not provide specific advice on treatment when newborns had prolonged clinical signs of infection or high levels of infection markers. All guidelines recommended using CBC or CRP, while only one included PCT.

Dr. van Herk and colleagues also compared the guidelines for each country with the survey responses of physicians from that country, and found most followed national guidelines on when to start or discontinue antibiotics.

"The diversity with regards to duration of antibiotic therapy in higher risk situations raises the question, what are safe strategies to minimize duration of antibiotic therapy without under-treatment of truly septic neonates?" the authors write. "Currently, the duration of antibiotic therapy is controversial even for proven infection. Prospective, international, multicenter trials studying newer infection markers with a safety endpoint may be helpful in answering this question."

NEW YORK (Reuters Health) - Clinical practice in management of early-onset sepsis (EOS) in newborns varies widely across Europe, North America and Asia, new survey results show.

National guidelines also disagree on when to start antibiotics in low-risk situations, and how to decide to stop therapy in high-risk scenarios, Dr. Wendy van Herk of Erasmus MC University Medical Center-Sophia Children's Hospital in Rotterdam, the Netherlands, and colleagues found."

A discussion leading to terms of a threshold to treat neonates with low infection risk, prospective studies ofstrategies regarding early discontinuation of unnecessary antibiotic therapy with safety endpoints acknowledging different backgrounds of health care systems, and clear and concise guidelines followed by research to study the impact are mandatory to improve management of term and late preterm infants at risk for EOS," they write in their report, online January 13 in The Pediatric Infectious Disease Journal.

Up to 15% of term and late-preterm neonates are evaluated for suspected EOS, and 10% receive intravenous antibiotics within the first three days of life, the researchers note. But the incidence of culture-proven EOS in term and late-preterm newborns is less than 0.1%, they add.

To investigate current management of suspected EOS, the researchers surveyed pediatricians and neonatologists and reviewed guidelines from Canada, the United States, the United Kingdom, Switzerland and Belgium. A total of 439 clinicians responded to the survey.

In response to a question about whether they would start antibiotic treatment in a scenario rated "low risk" for EOS, 29% of physicians said they would, 26% would not, and 45% said they would start treatment if the patients' laboratory markers were abnormal. Nearly all of the respondents (99%) said they would initiate antibiotics in a high-risk scenario.

In the low-risk situation, 89% said they would stop antibiotic treatment before 72 hours. In the high-risk scenario, 35% said they would stop antibiotics before 72 hours, 56% said they would continue treatment for five to seven days, and 9% said they would treat patients for more than seven days.

Overall, 31% of the survey respondents said they would base their decision to start antibiotic treatment on laboratory investigations, while 72% said they would do so when deciding to continue treatment. Most said they would use complete blood count (CBC) and C-reactive protein (CRP), while a small minority said they would use newer inflammation markers including procalcitonin (PCT) and interleukins.

While all the guidelines reviewed recommended treating newborns with clinical signs indicating infection, and re-evaluating whether patients needed more antibiotics at 36 to 48 hours, they did not provide specific advice on treatment when newborns had prolonged clinical signs of infection or high levels of infection markers. All guidelines recommended using CBC or CRP, while only one included PCT.

Dr. van Herk and colleagues also compared the guidelines for each country with the survey responses of physicians from that country, and found most followed national guidelines on when to start or discontinue antibiotics.

"The diversity with regards to duration of antibiotic therapy in higher risk situations raises the question, what are safe strategies to minimize duration of antibiotic therapy without under-treatment of truly septic neonates?" the authors write. "Currently, the duration of antibiotic therapy is controversial even for proven infection. Prospective, international, multicenter trials studying newer infection markers with a safety endpoint may be helpful in answering this question."

SAN DIEGO—The Society of Hospital Medicine (SHM) today named three new Masters in Hospital Medicine at HM16, the largest meeting dedicated to the hospital medicine specialty. The Master in Hospital Medicine (MHM) designation was introduced in 2010 to honor those who have uniquely distinguished themselves in hospital medicine through excellence in the field and healthcare as a whole.

“As hospital medicine continues to evolve, we look to experts in the field to lead us into the future with their innovation and vision,” SHM President Brian Harte, MD, SFHM, says. “These accomplished individuals have played foundational roles in hospital medicine’s growth and success and continue to ensure hospitalists are equipped with the tools and resources they need to provide the highest quality of patient care.”

SHM is proud to announce the following MHMs for their outstanding contributions:

• Tina L. Budnitz, MPH, MHM, for her leadership in advancing the hospital medicine movement and SHM. Throughout her time with SHM, Budnitz has led the development of the Core Competencies for Hospital Medicine to define the skills of a practicing hospitalist, launched Project BOOST, a mentored implementation program to improve care transitions that was recognized with the 2012 John M. Eisenberg Patient Safety and Quality Award and assisted in the development of SHM’s Leadership Academy and Certificate of Leadership Program, designed to build the healthcare leaders of tomorrow.
• Eric E. Howell, MD, MHM, Chief of the Division of Hospital Medicine at Johns Hopkins Bayview Medical Center in Baltimore, MD, in recognition of his foundational leadership in the hospital medicine movement and SHM. Dr. Howell has been instrumental in managing and implementing change in the hospital, including conducting research on the relationship between the emergency department and medicine floors as well as improving communication, throughput and patient outcomes. A past President of SHM, Dr. Howell serves as the Senior Physician Advisor to SHM’s Center for Hospital Innovation and Improvement and has mentored numerous hospitals and hospital medicine programs in more than six countries.
• Gregory Maynard, MD, MSc, MHM, Chief Quality Officer at the University of California Davis Medical Center in Sacramento, CA, in honor of his leadership in local, regional and national quality improvement efforts and related contributions to SHM’s quality improvement programs. A longtime member of the SHM Hospital Quality and Patient Safety Committee, Dr. Maynard played an integral role in creating and leading SHM’s mentored implementation programs to enhance care transitions, improve glycemic control and prevent venous thromboembolism (VTE). Dr. Maynard is nationally recognized in each of these areas, making significant contributions to the medical community.

For details on SHM’s fellowship designations, visit www.hospitalmedicine.org/fellows.

SAN DIEGO—The Society of Hospital Medicine (SHM) today named three new Masters in Hospital Medicine at HM16, the largest meeting dedicated to the hospital medicine specialty. The Master in Hospital Medicine (MHM) designation was introduced in 2010 to honor those who have uniquely distinguished themselves in hospital medicine through excellence in the field and healthcare as a whole.

“As hospital medicine continues to evolve, we look to experts in the field to lead us into the future with their innovation and vision,” SHM President Brian Harte, MD, SFHM, says. “These accomplished individuals have played foundational roles in hospital medicine’s growth and success and continue to ensure hospitalists are equipped with the tools and resources they need to provide the highest quality of patient care.”

SHM is proud to announce the following MHMs for their outstanding contributions:

• Tina L. Budnitz, MPH, MHM, for her leadership in advancing the hospital medicine movement and SHM. Throughout her time with SHM, Budnitz has led the development of the Core Competencies for Hospital Medicine to define the skills of a practicing hospitalist, launched Project BOOST, a mentored implementation program to improve care transitions that was recognized with the 2012 John M. Eisenberg Patient Safety and Quality Award and assisted in the development of SHM’s Leadership Academy and Certificate of Leadership Program, designed to build the healthcare leaders of tomorrow.
• Eric E. Howell, MD, MHM, Chief of the Division of Hospital Medicine at Johns Hopkins Bayview Medical Center in Baltimore, MD, in recognition of his foundational leadership in the hospital medicine movement and SHM. Dr. Howell has been instrumental in managing and implementing change in the hospital, including conducting research on the relationship between the emergency department and medicine floors as well as improving communication, throughput and patient outcomes. A past President of SHM, Dr. Howell serves as the Senior Physician Advisor to SHM’s Center for Hospital Innovation and Improvement and has mentored numerous hospitals and hospital medicine programs in more than six countries.
• Gregory Maynard, MD, MSc, MHM, Chief Quality Officer at the University of California Davis Medical Center in Sacramento, CA, in honor of his leadership in local, regional and national quality improvement efforts and related contributions to SHM’s quality improvement programs. A longtime member of the SHM Hospital Quality and Patient Safety Committee, Dr. Maynard played an integral role in creating and leading SHM’s mentored implementation programs to enhance care transitions, improve glycemic control and prevent venous thromboembolism (VTE). Dr. Maynard is nationally recognized in each of these areas, making significant contributions to the medical community.

For details on SHM’s fellowship designations, visit www.hospitalmedicine.org/fellows.

SAN DIEGO—The Society of Hospital Medicine (SHM) today named three new Masters in Hospital Medicine at HM16, the largest meeting dedicated to the hospital medicine specialty. The Master in Hospital Medicine (MHM) designation was introduced in 2010 to honor those who have uniquely distinguished themselves in hospital medicine through excellence in the field and healthcare as a whole.

“As hospital medicine continues to evolve, we look to experts in the field to lead us into the future with their innovation and vision,” SHM President Brian Harte, MD, SFHM, says. “These accomplished individuals have played foundational roles in hospital medicine’s growth and success and continue to ensure hospitalists are equipped with the tools and resources they need to provide the highest quality of patient care.”

SHM is proud to announce the following MHMs for their outstanding contributions:

• Tina L. Budnitz, MPH, MHM, for her leadership in advancing the hospital medicine movement and SHM. Throughout her time with SHM, Budnitz has led the development of the Core Competencies for Hospital Medicine to define the skills of a practicing hospitalist, launched Project BOOST, a mentored implementation program to improve care transitions that was recognized with the 2012 John M. Eisenberg Patient Safety and Quality Award and assisted in the development of SHM’s Leadership Academy and Certificate of Leadership Program, designed to build the healthcare leaders of tomorrow.
• Eric E. Howell, MD, MHM, Chief of the Division of Hospital Medicine at Johns Hopkins Bayview Medical Center in Baltimore, MD, in recognition of his foundational leadership in the hospital medicine movement and SHM. Dr. Howell has been instrumental in managing and implementing change in the hospital, including conducting research on the relationship between the emergency department and medicine floors as well as improving communication, throughput and patient outcomes. A past President of SHM, Dr. Howell serves as the Senior Physician Advisor to SHM’s Center for Hospital Innovation and Improvement and has mentored numerous hospitals and hospital medicine programs in more than six countries.
• Gregory Maynard, MD, MSc, MHM, Chief Quality Officer at the University of California Davis Medical Center in Sacramento, CA, in honor of his leadership in local, regional and national quality improvement efforts and related contributions to SHM’s quality improvement programs. A longtime member of the SHM Hospital Quality and Patient Safety Committee, Dr. Maynard played an integral role in creating and leading SHM’s mentored implementation programs to enhance care transitions, improve glycemic control and prevent venous thromboembolism (VTE). Dr. Maynard is nationally recognized in each of these areas, making significant contributions to the medical community.

For details on SHM’s fellowship designations, visit www.hospitalmedicine.org/fellows.

Presenter: Jordan Messler, MD, SHFM

Summary: The main objective of this lecture was to understand the culture that often limits physician engagement. It also offered insights on how to best understand motivators for engagement, and tried to focus on strategies to improve and create an environment for physician engagement.

Despite strong evidence, there remains a refusal to confront healthcare provider’s severe quality problems. There is a high rate of failure, considering that 80% of major initiatives don’t meet their objectives. Dr. Messler pointed out that the second principle of the "Key Characteristics of an Effective Hospital Medicine Group" is an engaged hospitalist. To make this more complicated, 40% of hospitalists report inpatient census that exceed safe levels at least once a month; and 52% of hospitalists have signs of burnout.

Dr. Messler explained are intrinsic and extrinsic motivators: the culture of the group will impact the extrinsic motivation factors when it tries to encourage physician to do their work because they expected of themselves, not because some else is looking over their shoulders. Among intrinsic motivators: a sense of autonomy, mastery and purpose drives a culture of not only do the work but also improve it. Some hospitalist groups are trying to explore new approaches, including protective time for physicians to allow them to get involved in committee and QI projects.

Applying behavioral economics concepts (science of human motivation) can help HMGs design incentives among such domains as inertia (by simplifying processes), immediacy (giving bonus right after achieving goals), mental accounting (using paper checks for rewards).

HM Takeaways:

• There is lack of awareness of physician disengagement.
• Burn out is the opposite of engagement and affects patient quality.
• There are intrinsic and extrinsic factors that drives engagement.
• By creating a culture of ownership, mastery, autonomy, and rediscovery of purpose and right mix of incentives physicians can engage more.
• SHM has an Engagement Survey that can help get to know baseline motivators driving among specific groups.

Dr. Villagra is a hospitalist in Batesville, Ark., and a member of Team Hospitalist.

Presenter: Jordan Messler, MD, SHFM

Summary: The main objective of this lecture was to understand the culture that often limits physician engagement. It also offered insights on how to best understand motivators for engagement, and tried to focus on strategies to improve and create an environment for physician engagement.

Despite strong evidence, there remains a refusal to confront healthcare provider’s severe quality problems. There is a high rate of failure, considering that 80% of major initiatives don’t meet their objectives. Dr. Messler pointed out that the second principle of the "Key Characteristics of an Effective Hospital Medicine Group" is an engaged hospitalist. To make this more complicated, 40% of hospitalists report inpatient census that exceed safe levels at least once a month; and 52% of hospitalists have signs of burnout.

Dr. Messler explained are intrinsic and extrinsic motivators: the culture of the group will impact the extrinsic motivation factors when it tries to encourage physician to do their work because they expected of themselves, not because some else is looking over their shoulders. Among intrinsic motivators: a sense of autonomy, mastery and purpose drives a culture of not only do the work but also improve it. Some hospitalist groups are trying to explore new approaches, including protective time for physicians to allow them to get involved in committee and QI projects.

Applying behavioral economics concepts (science of human motivation) can help HMGs design incentives among such domains as inertia (by simplifying processes), immediacy (giving bonus right after achieving goals), mental accounting (using paper checks for rewards).

HM Takeaways:

• There is lack of awareness of physician disengagement.
• Burn out is the opposite of engagement and affects patient quality.
• There are intrinsic and extrinsic factors that drives engagement.
• By creating a culture of ownership, mastery, autonomy, and rediscovery of purpose and right mix of incentives physicians can engage more.
• SHM has an Engagement Survey that can help get to know baseline motivators driving among specific groups.

Dr. Villagra is a hospitalist in Batesville, Ark., and a member of Team Hospitalist.

Presenter: Jordan Messler, MD, SHFM

Summary: The main objective of this lecture was to understand the culture that often limits physician engagement. It also offered insights on how to best understand motivators for engagement, and tried to focus on strategies to improve and create an environment for physician engagement.

Despite strong evidence, there remains a refusal to confront healthcare provider’s severe quality problems. There is a high rate of failure, considering that 80% of major initiatives don’t meet their objectives. Dr. Messler pointed out that the second principle of the "Key Characteristics of an Effective Hospital Medicine Group" is an engaged hospitalist. To make this more complicated, 40% of hospitalists report inpatient census that exceed safe levels at least once a month; and 52% of hospitalists have signs of burnout.

Dr. Messler explained are intrinsic and extrinsic motivators: the culture of the group will impact the extrinsic motivation factors when it tries to encourage physician to do their work because they expected of themselves, not because some else is looking over their shoulders. Among intrinsic motivators: a sense of autonomy, mastery and purpose drives a culture of not only do the work but also improve it. Some hospitalist groups are trying to explore new approaches, including protective time for physicians to allow them to get involved in committee and QI projects.

Applying behavioral economics concepts (science of human motivation) can help HMGs design incentives among such domains as inertia (by simplifying processes), immediacy (giving bonus right after achieving goals), mental accounting (using paper checks for rewards).

HM Takeaways:

• There is lack of awareness of physician disengagement.
• Burn out is the opposite of engagement and affects patient quality.
• There are intrinsic and extrinsic factors that drives engagement.
• By creating a culture of ownership, mastery, autonomy, and rediscovery of purpose and right mix of incentives physicians can engage more.
• SHM has an Engagement Survey that can help get to know baseline motivators driving among specific groups.

Dr. Villagra is a hospitalist in Batesville, Ark., and a member of Team Hospitalist.

Presenter: Jim Pile, MD, Cleveland Clinic

Summary: The following three infectious diagnoses are relatively uncommon but important not to miss as they are associated with high mortality, especially when diagnosis and treatment are delayed. Remembering these key points can help you make the diagnosis:

• Bacterial meningitis: Many patients do not have the classic triad—fever, nuchal rigidity, and altered mental status—but nearly all have at least one of these signs, and most have headache. The jolt accentuation test—horizontal movement of the head causing exacerbation of the headache—is more sensitive than nuchal rigidity in these cases. Diagnosis is confirmed by lumbar puncture. It appears safe to not to perform head CT in patients

• Spinal epidural abscess: Risk factors include DM, IV drug use, hemodialysis, UTI, trauma, epidural anesthesia, trauma/surgery. Presentation is acute to indolent and usually consists of four stages: central back pain, radicular pain, neurologic deficits, paralysis; fever variable. Checking ESR can be helpful as it is elevated in most cases. MRI is imaging study of choice. Initial management includes antibiotics to coverage Staph Aureus and gram negative rods and surgery consultation.
• Necrotizing soft tissue infection: Risk factors include DM, IV drug use, trauma/surgery, ETOH, immunosuppression (Type I); muscle trauma, skin integrity deficits (Type II). Clinical suspicion is paramount. Specific clues include: pain out of proportion, anesthesia, systemic toxicity, rapid progression, bullae/crepitus, and failure to respond to antibiotics. Initial management includes initiation of B-lactam/lactamase inhibitor or carbapenem plus clindamycin and MRSA coverage, imaging and prompt surgical consultation (as delayed/inadequate surgery associated with poor prognosis.

Key Takeaway

Clinical suspicion is key to diagnosis of bacterial meningitis, spinal epidural abscesses, and necrotizing soft tissue infections, and delays in diagnosis and treatment are associated with increased mortality.TH

Presenter: Jim Pile, MD, Cleveland Clinic

Summary: The following three infectious diagnoses are relatively uncommon but important not to miss as they are associated with high mortality, especially when diagnosis and treatment are delayed. Remembering these key points can help you make the diagnosis:

• Bacterial meningitis: Many patients do not have the classic triad—fever, nuchal rigidity, and altered mental status—but nearly all have at least one of these signs, and most have headache. The jolt accentuation test—horizontal movement of the head causing exacerbation of the headache—is more sensitive than nuchal rigidity in these cases. Diagnosis is confirmed by lumbar puncture. It appears safe to not to perform head CT in patients

• Spinal epidural abscess: Risk factors include DM, IV drug use, hemodialysis, UTI, trauma, epidural anesthesia, trauma/surgery. Presentation is acute to indolent and usually consists of four stages: central back pain, radicular pain, neurologic deficits, paralysis; fever variable. Checking ESR can be helpful as it is elevated in most cases. MRI is imaging study of choice. Initial management includes antibiotics to coverage Staph Aureus and gram negative rods and surgery consultation.
• Necrotizing soft tissue infection: Risk factors include DM, IV drug use, trauma/surgery, ETOH, immunosuppression (Type I); muscle trauma, skin integrity deficits (Type II). Clinical suspicion is paramount. Specific clues include: pain out of proportion, anesthesia, systemic toxicity, rapid progression, bullae/crepitus, and failure to respond to antibiotics. Initial management includes initiation of B-lactam/lactamase inhibitor or carbapenem plus clindamycin and MRSA coverage, imaging and prompt surgical consultation (as delayed/inadequate surgery associated with poor prognosis.

Key Takeaway

Clinical suspicion is key to diagnosis of bacterial meningitis, spinal epidural abscesses, and necrotizing soft tissue infections, and delays in diagnosis and treatment are associated with increased mortality.TH

Presenter: Jim Pile, MD, Cleveland Clinic

Summary: The following three infectious diagnoses are relatively uncommon but important not to miss as they are associated with high mortality, especially when diagnosis and treatment are delayed. Remembering these key points can help you make the diagnosis:

• Bacterial meningitis: Many patients do not have the classic triad—fever, nuchal rigidity, and altered mental status—but nearly all have at least one of these signs, and most have headache. The jolt accentuation test—horizontal movement of the head causing exacerbation of the headache—is more sensitive than nuchal rigidity in these cases. Diagnosis is confirmed by lumbar puncture. It appears safe to not to perform head CT in patients

• Spinal epidural abscess: Risk factors include DM, IV drug use, hemodialysis, UTI, trauma, epidural anesthesia, trauma/surgery. Presentation is acute to indolent and usually consists of four stages: central back pain, radicular pain, neurologic deficits, paralysis; fever variable. Checking ESR can be helpful as it is elevated in most cases. MRI is imaging study of choice. Initial management includes antibiotics to coverage Staph Aureus and gram negative rods and surgery consultation.
• Necrotizing soft tissue infection: Risk factors include DM, IV drug use, trauma/surgery, ETOH, immunosuppression (Type I); muscle trauma, skin integrity deficits (Type II). Clinical suspicion is paramount. Specific clues include: pain out of proportion, anesthesia, systemic toxicity, rapid progression, bullae/crepitus, and failure to respond to antibiotics. Initial management includes initiation of B-lactam/lactamase inhibitor or carbapenem plus clindamycin and MRSA coverage, imaging and prompt surgical consultation (as delayed/inadequate surgery associated with poor prognosis.

Key Takeaway

Clinical suspicion is key to diagnosis of bacterial meningitis, spinal epidural abscesses, and necrotizing soft tissue infections, and delays in diagnosis and treatment are associated with increased mortality.TH

HM16 Presenters: Mangla Gulati, MD, FACP, FHM, and Ian Jenkins, MD

Summary: There is some evidence that hospital adverse events may be decreasing. The Agency for Healthcare Research and Quality (AHRQ) report of Partnership for Patients data found that there were 1.3 million hospital-acquired conditions prevented from 2011-2013, translating to 50,000 lives saved and $12 billion in savings. However, there is still much work to be done. Here are some major themes from the recent literature that may inform your own QI projects:

• Electronic medical records (EMR): Increased adoption raises concerns for unintended consequences which could detract from patient safety. These are derived from case reports, claims databases, reports through patient safety organizations. Consider reviewing alerts, advisories, and hard-stops within your hospital’s EMR.
• Improving diagnosis: Misdiagnosis affects 10% of Americans but measurement of this phenomenon remains difficult. Strategies to improve diagnosis include: focus on collaboration, teaching diagnostic skills, IT and algorithmic support, feedback and blame reduction, and reimbursement reform. There is growing recognition that hospitalists are well positioned to engage in these efforts.
• Hand hygiene: Multiple culture and environmental contributors to poor compliance (i.e., 40% compliance rate) and few good intervention studies. Recent studies have focused on the development of cause-specific plans and targeted interventions. Consider applying a targeted solutions tool to a project at your hospital.
• “Second victim”: Healthcare providers frequently experience emotional distress following patient safety events but there is a lack of resources to support providers after such an event. Consider implementing a “care for the caregiver” program at your hospital.
• Sepsis: North Shore-LIJ hospital system (in collaboration with the IHI) received the 2014 Eisenberg Award for developing and implementing a Sepsis Recognition Program and tool-kit. Such collaborations may be useful for driving and magnifying your QI initiatives.
• Patient experience: Recent studies emphasize the importance of patients being actively involved in their medical decisions and providing meaningful feedback. Consider implementing a patient/family council and getting involved with local patient experience initiatives.
• Incident reporting systems (IRS): Widespread under-reporting raises concerns over the value of IRS. Consider modifying or minimizing IRS and/or giving reports to local units to ignite safety culture.
• Discharge before noon (DBN): Delayed discharges may result in lost revenue and poor patient satisfaction. Wertheimer et al. reported on a successful intervention to increase DBN in the Journal of Hospital Medicine. Check out their intervention and consider something similar at your hospital.
• Patient monitoring: Vital sign measurements are often poorly timed, integrated and/or communicated. Recent studies of wireless Electronic Physiologic Surveillance System devices in hospitals have shown positive outcomes.TH

HM16 Presenters: Mangla Gulati, MD, FACP, FHM, and Ian Jenkins, MD

Summary: There is some evidence that hospital adverse events may be decreasing. The Agency for Healthcare Research and Quality (AHRQ) report of Partnership for Patients data found that there were 1.3 million hospital-acquired conditions prevented from 2011-2013, translating to 50,000 lives saved and $12 billion in savings. However, there is still much work to be done. Here are some major themes from the recent literature that may inform your own QI projects:

• Electronic medical records (EMR): Increased adoption raises concerns for unintended consequences which could detract from patient safety. These are derived from case reports, claims databases, reports through patient safety organizations. Consider reviewing alerts, advisories, and hard-stops within your hospital’s EMR.
• Improving diagnosis: Misdiagnosis affects 10% of Americans but measurement of this phenomenon remains difficult. Strategies to improve diagnosis include: focus on collaboration, teaching diagnostic skills, IT and algorithmic support, feedback and blame reduction, and reimbursement reform. There is growing recognition that hospitalists are well positioned to engage in these efforts.
• Hand hygiene: Multiple culture and environmental contributors to poor compliance (i.e., 40% compliance rate) and few good intervention studies. Recent studies have focused on the development of cause-specific plans and targeted interventions. Consider applying a targeted solutions tool to a project at your hospital.
• “Second victim”: Healthcare providers frequently experience emotional distress following patient safety events but there is a lack of resources to support providers after such an event. Consider implementing a “care for the caregiver” program at your hospital.
• Sepsis: North Shore-LIJ hospital system (in collaboration with the IHI) received the 2014 Eisenberg Award for developing and implementing a Sepsis Recognition Program and tool-kit. Such collaborations may be useful for driving and magnifying your QI initiatives.
• Patient experience: Recent studies emphasize the importance of patients being actively involved in their medical decisions and providing meaningful feedback. Consider implementing a patient/family council and getting involved with local patient experience initiatives.
• Incident reporting systems (IRS): Widespread under-reporting raises concerns over the value of IRS. Consider modifying or minimizing IRS and/or giving reports to local units to ignite safety culture.
• Discharge before noon (DBN): Delayed discharges may result in lost revenue and poor patient satisfaction. Wertheimer et al. reported on a successful intervention to increase DBN in the Journal of Hospital Medicine. Check out their intervention and consider something similar at your hospital.
• Patient monitoring: Vital sign measurements are often poorly timed, integrated and/or communicated. Recent studies of wireless Electronic Physiologic Surveillance System devices in hospitals have shown positive outcomes.TH

HM16 Presenters: Mangla Gulati, MD, FACP, FHM, and Ian Jenkins, MD

Summary: There is some evidence that hospital adverse events may be decreasing. The Agency for Healthcare Research and Quality (AHRQ) report of Partnership for Patients data found that there were 1.3 million hospital-acquired conditions prevented from 2011-2013, translating to 50,000 lives saved and $12 billion in savings. However, there is still much work to be done. Here are some major themes from the recent literature that may inform your own QI projects:

• Electronic medical records (EMR): Increased adoption raises concerns for unintended consequences which could detract from patient safety. These are derived from case reports, claims databases, reports through patient safety organizations. Consider reviewing alerts, advisories, and hard-stops within your hospital’s EMR.
• Improving diagnosis: Misdiagnosis affects 10% of Americans but measurement of this phenomenon remains difficult. Strategies to improve diagnosis include: focus on collaboration, teaching diagnostic skills, IT and algorithmic support, feedback and blame reduction, and reimbursement reform. There is growing recognition that hospitalists are well positioned to engage in these efforts.
• Hand hygiene: Multiple culture and environmental contributors to poor compliance (i.e., 40% compliance rate) and few good intervention studies. Recent studies have focused on the development of cause-specific plans and targeted interventions. Consider applying a targeted solutions tool to a project at your hospital.
• “Second victim”: Healthcare providers frequently experience emotional distress following patient safety events but there is a lack of resources to support providers after such an event. Consider implementing a “care for the caregiver” program at your hospital.
• Sepsis: North Shore-LIJ hospital system (in collaboration with the IHI) received the 2014 Eisenberg Award for developing and implementing a Sepsis Recognition Program and tool-kit. Such collaborations may be useful for driving and magnifying your QI initiatives.
• Patient experience: Recent studies emphasize the importance of patients being actively involved in their medical decisions and providing meaningful feedback. Consider implementing a patient/family council and getting involved with local patient experience initiatives.
• Incident reporting systems (IRS): Widespread under-reporting raises concerns over the value of IRS. Consider modifying or minimizing IRS and/or giving reports to local units to ignite safety culture.
• Discharge before noon (DBN): Delayed discharges may result in lost revenue and poor patient satisfaction. Wertheimer et al. reported on a successful intervention to increase DBN in the Journal of Hospital Medicine. Check out their intervention and consider something similar at your hospital.
• Patient monitoring: Vital sign measurements are often poorly timed, integrated and/or communicated. Recent studies of wireless Electronic Physiologic Surveillance System devices in hospitals have shown positive outcomes.TH

Thanks to all who attended HM16 in San Diego! From the featured speakers—Acting Assistant Secretary for Health in the U.S. Department of Health and Human Services Karen DeSalvo, MD, MPH, MSc, and faculty—to the attendees and staff, it would not have been such a success without you and your enthusiasm.

Join us again in 2017! Save the dates for another premier networking and educational event in Las Vegas. HM17 is slated for May 1–4, 2017, at Mandalay Bay Resort and Casino. More details will be coming soon.

Thanks to all who attended HM16 in San Diego! From the featured speakers—Acting Assistant Secretary for Health in the U.S. Department of Health and Human Services Karen DeSalvo, MD, MPH, MSc, and faculty—to the attendees and staff, it would not have been such a success without you and your enthusiasm.

Join us again in 2017! Save the dates for another premier networking and educational event in Las Vegas. HM17 is slated for May 1–4, 2017, at Mandalay Bay Resort and Casino. More details will be coming soon.

Thanks to all who attended HM16 in San Diego! From the featured speakers—Acting Assistant Secretary for Health in the U.S. Department of Health and Human Services Karen DeSalvo, MD, MPH, MSc, and faculty—to the attendees and staff, it would not have been such a success without you and your enthusiasm.

Join us again in 2017! Save the dates for another premier networking and educational event in Las Vegas. HM17 is slated for May 1–4, 2017, at Mandalay Bay Resort and Casino. More details will be coming soon.

NEW YORK (Reuters Health) - The Sepsis Definitions Task Force, using expanded quantitative information, has updated its definitions for sepsis and septic shock and the clinical criteria underlying them.

Two reports and one summary communication published in JAMA February 23 detail the processes used to reach the consensus

definitions that have remained largely unchanged for more than two decades.

"The new definitions and clinical criteria of sepsis and septic shock are aimed to help clinicians at the bedside recognize these deadly syndromes and start therapy promptly," Dr. Christopher W. Seymour, from the University of Pittsburgh School of Medicine in Pennsylvania, told Reuters Health by email.

"After two years of deliberations and research, we were surprised to uncover the broad differences in how clinicians approach sepsis, and variety of criteria used in septic shock trials in the past decade. This mandated a re-examination of the criteria, strong efforts to speak a common language, and generate simple, easy to use criteria," Dr. Seymour said.

Dr. Seymour and colleagues recommended elimination of the terms sepsis syndrome, septicemia, and severe sepsis and settled on the definition of sepsis as "life-threatening organ dysfunction due to a dysregulated host response to infection."

They explored several sets of clinical criteria and their predictive validity for hospital mortality, including the Sequential Organ Function Assessment (SOFA), Logistic Organ Dysfunction System (LODS), systemic inflammatory response syndrome (SIRS), and a simplified qSOFA model that included Glasgow Coma Scale (GCS) score of 13 or less, systolic blood pressure of 100 mm Hg or less, and respiratory rate of 22/min or more (1 point each; score range, 0-3).

For intensive care unit encounters with suspected infection, SOFA came out on top, whereas for encounters with suspected infection outside of the ICU, qSOFA offered the best predictive validity for in-hospital mortality.

"Sepsis has no gold standard for diagnosis," Dr. Seymour said. "Given its complex pathophysiology and our evolving knowledge base, the current definition and criteria for sepsis represent a first step. Our field will need to continue to embark on improvements in the practicality, validity, and scientific rationale for sepsis definitions/criteria in future iterations."

He added,"We also hope that physicians recognize that, for the first time, these criteria derive from new data analyses in real patients. More than 700,000 encounters in 170 hospitals were studied to evaluate existing and new sepsis criteria."

Dr. Manu Shankar-Hari, from Guy's and St. Thomas' NHS Foundation Trust, London, UK, and colleagues reviewed 44 studies of septic shock involving 166,479 patients and used a Delphi process to arrive at the new consensus definition: "septic shock is defined as a subset of sepsis in which underlying circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than sepsis alone."

Dr. Shankar-Hari told Reuters Health by email, "The proposed definition for septic shock is a paradigm shift in illness concept. We wanted to provide consistency in diagnosing septic shock. The epidemiology of this illness as we measure currently is messy."

After examining six possible sets of clinical criteria, the group identified two criteria that proved most consistent with the proposed septic shock definition: hypotension requiring use of vasopressors to maintain mean blood pressure of 65 mm Hg or greater and having a serum lactate level greater than 2 mmol/L persisting after adequate fluid resuscitation.

In their summary report, Dr. Clifford S. Deutschman, from Hofstra-Northwell School of Medicine, Feinstein Institute for Medical Research, New Hyde Park, New York, and colleagues on the Task Force write, "The proposed criteria should aid diagnostic categorization once initial assessment and immediate management are completed. qSOFA or SOFA may at some point be used as entry criteria for clinical trials."

"Greater clarity and consistency will also facilitate research and more accurate coding," they add.

Dr. Edward Abraham, from Wake Forest School of Medicine, Winston Salem, North Carolina, who wrote an editorial related to these reports, told Reuters Health by email, "While the new definitions advance the field, particularly from an epidemiologic viewpoint and potentially in helping to identify the economic impact associated with sepsis and septic shock, they are only of limited help in defining care for an individual patient or in designing clinical trials to examine new therapies for sepsis."

"As noted in the editorial, more discriminatory definitions, based on specific cellular and genomic alterations, are necessary to truly affect care for individual patients and to assist in the development of novel therapeutic approaches to sepsis and septic shock," he said.

A number of organizations supported this research and a number of coauthors reported disclosures.

NEW YORK (Reuters Health) - The Sepsis Definitions Task Force, using expanded quantitative information, has updated its definitions for sepsis and septic shock and the clinical criteria underlying them.

Two reports and one summary communication published in JAMA February 23 detail the processes used to reach the consensus

definitions that have remained largely unchanged for more than two decades.

"The new definitions and clinical criteria of sepsis and septic shock are aimed to help clinicians at the bedside recognize these deadly syndromes and start therapy promptly," Dr. Christopher W. Seymour, from the University of Pittsburgh School of Medicine in Pennsylvania, told Reuters Health by email.

"After two years of deliberations and research, we were surprised to uncover the broad differences in how clinicians approach sepsis, and variety of criteria used in septic shock trials in the past decade. This mandated a re-examination of the criteria, strong efforts to speak a common language, and generate simple, easy to use criteria," Dr. Seymour said.

Dr. Seymour and colleagues recommended elimination of the terms sepsis syndrome, septicemia, and severe sepsis and settled on the definition of sepsis as "life-threatening organ dysfunction due to a dysregulated host response to infection."

They explored several sets of clinical criteria and their predictive validity for hospital mortality, including the Sequential Organ Function Assessment (SOFA), Logistic Organ Dysfunction System (LODS), systemic inflammatory response syndrome (SIRS), and a simplified qSOFA model that included Glasgow Coma Scale (GCS) score of 13 or less, systolic blood pressure of 100 mm Hg or less, and respiratory rate of 22/min or more (1 point each; score range, 0-3).

For intensive care unit encounters with suspected infection, SOFA came out on top, whereas for encounters with suspected infection outside of the ICU, qSOFA offered the best predictive validity for in-hospital mortality.

"Sepsis has no gold standard for diagnosis," Dr. Seymour said. "Given its complex pathophysiology and our evolving knowledge base, the current definition and criteria for sepsis represent a first step. Our field will need to continue to embark on improvements in the practicality, validity, and scientific rationale for sepsis definitions/criteria in future iterations."

He added,"We also hope that physicians recognize that, for the first time, these criteria derive from new data analyses in real patients. More than 700,000 encounters in 170 hospitals were studied to evaluate existing and new sepsis criteria."

Dr. Manu Shankar-Hari, from Guy's and St. Thomas' NHS Foundation Trust, London, UK, and colleagues reviewed 44 studies of septic shock involving 166,479 patients and used a Delphi process to arrive at the new consensus definition: "septic shock is defined as a subset of sepsis in which underlying circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than sepsis alone."

Dr. Shankar-Hari told Reuters Health by email, "The proposed definition for septic shock is a paradigm shift in illness concept. We wanted to provide consistency in diagnosing septic shock. The epidemiology of this illness as we measure currently is messy."

After examining six possible sets of clinical criteria, the group identified two criteria that proved most consistent with the proposed septic shock definition: hypotension requiring use of vasopressors to maintain mean blood pressure of 65 mm Hg or greater and having a serum lactate level greater than 2 mmol/L persisting after adequate fluid resuscitation.

In their summary report, Dr. Clifford S. Deutschman, from Hofstra-Northwell School of Medicine, Feinstein Institute for Medical Research, New Hyde Park, New York, and colleagues on the Task Force write, "The proposed criteria should aid diagnostic categorization once initial assessment and immediate management are completed. qSOFA or SOFA may at some point be used as entry criteria for clinical trials."

"Greater clarity and consistency will also facilitate research and more accurate coding," they add.

Dr. Edward Abraham, from Wake Forest School of Medicine, Winston Salem, North Carolina, who wrote an editorial related to these reports, told Reuters Health by email, "While the new definitions advance the field, particularly from an epidemiologic viewpoint and potentially in helping to identify the economic impact associated with sepsis and septic shock, they are only of limited help in defining care for an individual patient or in designing clinical trials to examine new therapies for sepsis."

"As noted in the editorial, more discriminatory definitions, based on specific cellular and genomic alterations, are necessary to truly affect care for individual patients and to assist in the development of novel therapeutic approaches to sepsis and septic shock," he said.

A number of organizations supported this research and a number of coauthors reported disclosures.

NEW YORK (Reuters Health) - The Sepsis Definitions Task Force, using expanded quantitative information, has updated its definitions for sepsis and septic shock and the clinical criteria underlying them.

Two reports and one summary communication published in JAMA February 23 detail the processes used to reach the consensus

definitions that have remained largely unchanged for more than two decades.

"The new definitions and clinical criteria of sepsis and septic shock are aimed to help clinicians at the bedside recognize these deadly syndromes and start therapy promptly," Dr. Christopher W. Seymour, from the University of Pittsburgh School of Medicine in Pennsylvania, told Reuters Health by email.

"After two years of deliberations and research, we were surprised to uncover the broad differences in how clinicians approach sepsis, and variety of criteria used in septic shock trials in the past decade. This mandated a re-examination of the criteria, strong efforts to speak a common language, and generate simple, easy to use criteria," Dr. Seymour said.

Dr. Seymour and colleagues recommended elimination of the terms sepsis syndrome, septicemia, and severe sepsis and settled on the definition of sepsis as "life-threatening organ dysfunction due to a dysregulated host response to infection."

They explored several sets of clinical criteria and their predictive validity for hospital mortality, including the Sequential Organ Function Assessment (SOFA), Logistic Organ Dysfunction System (LODS), systemic inflammatory response syndrome (SIRS), and a simplified qSOFA model that included Glasgow Coma Scale (GCS) score of 13 or less, systolic blood pressure of 100 mm Hg or less, and respiratory rate of 22/min or more (1 point each; score range, 0-3).

For intensive care unit encounters with suspected infection, SOFA came out on top, whereas for encounters with suspected infection outside of the ICU, qSOFA offered the best predictive validity for in-hospital mortality.

"Sepsis has no gold standard for diagnosis," Dr. Seymour said. "Given its complex pathophysiology and our evolving knowledge base, the current definition and criteria for sepsis represent a first step. Our field will need to continue to embark on improvements in the practicality, validity, and scientific rationale for sepsis definitions/criteria in future iterations."

He added,"We also hope that physicians recognize that, for the first time, these criteria derive from new data analyses in real patients. More than 700,000 encounters in 170 hospitals were studied to evaluate existing and new sepsis criteria."

Dr. Manu Shankar-Hari, from Guy's and St. Thomas' NHS Foundation Trust, London, UK, and colleagues reviewed 44 studies of septic shock involving 166,479 patients and used a Delphi process to arrive at the new consensus definition: "septic shock is defined as a subset of sepsis in which underlying circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than sepsis alone."

Dr. Shankar-Hari told Reuters Health by email, "The proposed definition for septic shock is a paradigm shift in illness concept. We wanted to provide consistency in diagnosing septic shock. The epidemiology of this illness as we measure currently is messy."

After examining six possible sets of clinical criteria, the group identified two criteria that proved most consistent with the proposed septic shock definition: hypotension requiring use of vasopressors to maintain mean blood pressure of 65 mm Hg or greater and having a serum lactate level greater than 2 mmol/L persisting after adequate fluid resuscitation.

In their summary report, Dr. Clifford S. Deutschman, from Hofstra-Northwell School of Medicine, Feinstein Institute for Medical Research, New Hyde Park, New York, and colleagues on the Task Force write, "The proposed criteria should aid diagnostic categorization once initial assessment and immediate management are completed. qSOFA or SOFA may at some point be used as entry criteria for clinical trials."

"Greater clarity and consistency will also facilitate research and more accurate coding," they add.

Dr. Edward Abraham, from Wake Forest School of Medicine, Winston Salem, North Carolina, who wrote an editorial related to these reports, told Reuters Health by email, "While the new definitions advance the field, particularly from an epidemiologic viewpoint and potentially in helping to identify the economic impact associated with sepsis and septic shock, they are only of limited help in defining care for an individual patient or in designing clinical trials to examine new therapies for sepsis."

"As noted in the editorial, more discriminatory definitions, based on specific cellular and genomic alterations, are necessary to truly affect care for individual patients and to assist in the development of novel therapeutic approaches to sepsis and septic shock," he said.

A number of organizations supported this research and a number of coauthors reported disclosures.

Physicians Nasim Afsar, MD, SFHM, and Eric Howell, MD, SFHM, presented key leadership lessons to a standing-room-only audience at Hospital Medicine 2016, the “Year of the Hospitalist.” The value of leadership and management skills is important in every day decisions from co-management of patients to motivating your teams.

Dr. Afsar and Dr. Howell went into detailed tips for these leadership lessons:

1. Decision-making bias. It is important to be aware of bias in decisions. A technique to evaluate a decision and “de-bias” is the WRAP process: Widen your options, Reality-test your assumptions, Attain distance before deciding, and Prepare to be wrong.
2. Performance management. Feedback and 360 evaluations are helpful tools in appraising performance.
3. Motivation can be intrinsic or extrinsic. Intrinsic motivation is essential for non-routine high level work in medicine. Understanding the motivation of a team member is very useful to the team leader.
4. Groups versus teams. The composition of a team is crucial to success. It is also important to be aware of team limitations and plan for these potential limitations.
5. Persuasion and influence. Six principles of persuasion are:

1. Demonstrate trustworthiness and expertise.
2. Social proof. Highlight existing norms or set new norms.
3. Highlight similarities.
4. A win-win situation with concessions shows willingness to participate.
5. Reach agreement.
6. An option that appears to be a rare offer is more desirable.

Key Takeaways

• Consistently using a standard decision-making process, such as WRAP, can ensure better decision making.
• Financial compensation can be detrimental to intrinsic motivation and worsen performance.
• Make a conscious decision about when you need a group to help make decisions versus a team to work towards a common goal.
• Set specific goals for performance during feedback: include timeline, particular actions, and results that are expected.
• Social proof can be a powerful tool in persuasion.
• The SHM Leadership Academy is available to hospitalists interested in expanding leadership skills. TH

Dr. Hale is a pediatric hospitalist at Floating Hospital for Children at Tufts University Medical Center in Boston, and a former member of Team Hospitalist.

Physicians Nasim Afsar, MD, SFHM, and Eric Howell, MD, SFHM, presented key leadership lessons to a standing-room-only audience at Hospital Medicine 2016, the “Year of the Hospitalist.” The value of leadership and management skills is important in every day decisions from co-management of patients to motivating your teams.

Dr. Afsar and Dr. Howell went into detailed tips for these leadership lessons:

1. Decision-making bias. It is important to be aware of bias in decisions. A technique to evaluate a decision and “de-bias” is the WRAP process: Widen your options, Reality-test your assumptions, Attain distance before deciding, and Prepare to be wrong.
2. Performance management. Feedback and 360 evaluations are helpful tools in appraising performance.
3. Motivation can be intrinsic or extrinsic. Intrinsic motivation is essential for non-routine high level work in medicine. Understanding the motivation of a team member is very useful to the team leader.
4. Groups versus teams. The composition of a team is crucial to success. It is also important to be aware of team limitations and plan for these potential limitations.
5. Persuasion and influence. Six principles of persuasion are:

1. Demonstrate trustworthiness and expertise.
2. Social proof. Highlight existing norms or set new norms.
3. Highlight similarities.
4. A win-win situation with concessions shows willingness to participate.
5. Reach agreement.
6. An option that appears to be a rare offer is more desirable.

Key Takeaways

• Consistently using a standard decision-making process, such as WRAP, can ensure better decision making.
• Financial compensation can be detrimental to intrinsic motivation and worsen performance.
• Make a conscious decision about when you need a group to help make decisions versus a team to work towards a common goal.
• Set specific goals for performance during feedback: include timeline, particular actions, and results that are expected.
• Social proof can be a powerful tool in persuasion.
• The SHM Leadership Academy is available to hospitalists interested in expanding leadership skills. TH

Dr. Hale is a pediatric hospitalist at Floating Hospital for Children at Tufts University Medical Center in Boston, and a former member of Team Hospitalist.

Physicians Nasim Afsar, MD, SFHM, and Eric Howell, MD, SFHM, presented key leadership lessons to a standing-room-only audience at Hospital Medicine 2016, the “Year of the Hospitalist.” The value of leadership and management skills is important in every day decisions from co-management of patients to motivating your teams.

Dr. Afsar and Dr. Howell went into detailed tips for these leadership lessons:

1. Decision-making bias. It is important to be aware of bias in decisions. A technique to evaluate a decision and “de-bias” is the WRAP process: Widen your options, Reality-test your assumptions, Attain distance before deciding, and Prepare to be wrong.
2. Performance management. Feedback and 360 evaluations are helpful tools in appraising performance.
3. Motivation can be intrinsic or extrinsic. Intrinsic motivation is essential for non-routine high level work in medicine. Understanding the motivation of a team member is very useful to the team leader.
4. Groups versus teams. The composition of a team is crucial to success. It is also important to be aware of team limitations and plan for these potential limitations.
5. Persuasion and influence. Six principles of persuasion are:

1. Demonstrate trustworthiness and expertise.
2. Social proof. Highlight existing norms or set new norms.
3. Highlight similarities.
4. A win-win situation with concessions shows willingness to participate.
5. Reach agreement.
6. An option that appears to be a rare offer is more desirable.

Key Takeaways

• Consistently using a standard decision-making process, such as WRAP, can ensure better decision making.
• Financial compensation can be detrimental to intrinsic motivation and worsen performance.
• Make a conscious decision about when you need a group to help make decisions versus a team to work towards a common goal.
• Set specific goals for performance during feedback: include timeline, particular actions, and results that are expected.
• Social proof can be a powerful tool in persuasion.
• The SHM Leadership Academy is available to hospitalists interested in expanding leadership skills. TH

Dr. Hale is a pediatric hospitalist at Floating Hospital for Children at Tufts University Medical Center in Boston, and a former member of Team Hospitalist.